Office and Business Owner Quote Request

Complete the following information if you would like to obtain a quote. Please understand this is not an application. An application will be sent to you if coverage is desired.

All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.

Personal Information

* Last Name

* First Name

Business Name

Street Address

City

State

Zip Code

Phone Number

Alternate Telephone

Fax Number

Email Address

Underwriting Information

What is the nature of your business?

Is the business a corporation, partnership, or sole proprietorship?

Corporation

Partnership

Sole Proprietorship

Number of owners

Number of Employees

Payroll of Owners

Payroll of Employees

Total annual gross receipts

Business License Number

License Type

Years of experience

Years operated under current name

Other business names

Is this business open 24 hours a day?

Yes

No

Any deep frying (food)?

Yes

No

Is there any manufacturing, mixing, re-labeling or repackaging of products?

Yes

No

Is there filling of propane tanks?

Yes

No

Please describe the nature of your business and ANY unusual exposures:

Building & Property Information

Total square footage of the building your business is in

Total square footage of your business only

Total square footage of the customer area only

How many stories is it?

If two stories, what is the ground floor square footage?

What is the construction type?

What type of roof covering?

Was the roof updated?

Yes

No

If yes, what year?

What is the distance to fire protection?

Is the business in a brush area?

Yes

No

Do you have a storage area more than 1500 sq. ft?

Yes

No

Are there smoke detectors at this location?

Yes

No

Are there fire extinguishers?

Yes

No

Are there deadbolts on all doors?

Yes

No

Are there circuit breakers?

Yes

No

Is the electrical updated?

Yes

No

Is the heating / air conditioning thermostatically controlled?

Yes

No

Is the heating/ air conditioning central?

Yes

No

Has the plumbing been updated?

Yes

No

If yes, what year was the plumbing updated?

Does the building have interior automatic fire sprinklers?

Yes

No

Is there a theft alarm?

Yes

No

Is there a fire alarm?

Yes

No

Are there any restaurants in your building

Yes

No

Are there any restaurants in the building next to your business?

Yes

No

Claims Information

Were there any losses or claims in the last 5 years?

Yes

No

If yes, what is the date, amount paid and description of each loss or claim?

Coverage Information

Current Insurance Company

How much are you paying now?

What is the liability limit requested?

What is the building limit requested?

What is the building deductible requested?

What is the business personal property (contents) limit requested?

What is the contents deductible requested?

What is the loss of income requested?

Questions or Comments

Best Time To Contact You

Please let us know the best time to call and discuss your quote.

Morning

Afternoon

Evening

Anytime

Or Specify Other:

Before submitting, type in required validation security code: 6dgu7b

* Required Fields

This web site may contain concepts that have legal, accounting and tax implications. It is not intended to provide legal, accounting or tax advice. You may wish to consult a competent attorney, tax advisor, or accountant.